The quality of life in patients with Parkinson's disease: Focus on gender difference

Abstract Background To improve understanding of gender differences on quality of life (QoL) in patients with Parkinson's disease (PWP) of a different race, the differences of clinical features and health‐related quality of life (HRQoL) between male and female PWP were studied in a small cohort early to middle stage of Chinese PWP. Methods A cross‐sectional study was carried out. PWP were consecutively included from April 2020 to July 2021 in Beijing Rehabilitation Hospital. HRQoL, motor symptoms, and nonmotor symptoms in each patient were evaluated. The differences of demographic, motor symptoms assessments, nonmotor symptoms assessments, and QoL between two gender groups were tested using t‐test statistics, Mann–Whitney–Wilcoxon test, or χ 2 depending on the data type. To eliminate the possible factors contributing to the QoL, linear regression models were constructed to sort out the effect of gender. Results One hundred and sixty‐two Parkinson's disease (PD) patients were included. Demographic, clinical characteristics, and symptom scale assessments had no statistical differences except for levodopa equivalent daily dose, Hamilton Anxiety Rating Score, REM sleep behavior disorder sleep questionnaire, and Hyposmia Rating Scale score. After baseline imbalance corrections, a significantly higher score of PD Questionnaire‐39 (PDQ‐39) in female than in male patients(p<.05) was found. In the questionnaire, summary Index and bodily discomfort, stigma, and emotional well‐being subscores were the main contribution differences. Conclusions Gender differences are associated with the QoL in the early to middle stage PWP in China. Female patients have poorer QoL than male patients, especially bodily discomfort, stigma, and emotional well‐being.


INTRODUCTION
Parkinson's disease (PD) is a chronic degenerative disease characterized by motor symptoms such as bradykinesia, rest tremor, rigidity, and a variety of nonmotor symptoms, including depression, memory loss, hyposmia, and gastrointestinal and sleep dysfunction, which lead to impairment in activities of daily living and a decline in quality of life (QoL) (Meoni et al., 2020).
As shown in Table 1, most of the studies show significantly better QoL of female patients than male patients (Augustine et al., 2015;Balash et al., 2019;Behari et al., 2005;Dahodwala et al., 2016;Hristova et al., 2009;Kuopio et al., 2000;Yoon et al., 2017). But some studies show no significant difference (Abraham et al., 2019;Carod-Artal et al., 2007;Kim et al., 2019;Lubomski et al., 2014), and one study shows significantly better QoL of PD women than PD men. Furthermore, most of the research focused on Europeans, Americans, Australians, and Asians in Korea and India. To our knowledge, there are limited studies on sex differences in QoL in the Chinese PD population. The number of PWP in China accounted for approximately 23% of the entire global PD population and has a rapid increase (Collaborators GPsD, 2019). The accurate identification of gender difference is important to tailor treatment, predict prognosis, and contentment other personal and social needs in PD patients (Georgiev et al., 2017).
Therefore, we sought to evaluate the gender differences in QoL in a Chinese PD population. Meanwhile, we also evaluated the differences in clinical features, such as motor and nonmotor symptoms.

Study population
A cross-sectional study was performed on consecutive PWP attending our inpatient rehabilitation in Beijing Rehabilitation Hospital from April 2020 to July 2021. Inclusion criteria were as follows: (1)

Clinical assessments
The Movement Disorder Society-Sponsored Revision of the Unified Parkinson's Disease Rating Scale (MDS-UPDRS) was used to assess PD motor functions (C. G. Goetz et al., 2007), and the H&Y stage was used to assess clinical stage (Hoehn & Yahr, 1967 Nonmotor symptoms were evaluated using the following scales: Montreal Cognitive Assessment (MoCA) for cognitive function, Hamilton Depression Rating Scale (HAMD) for depression (Hamilton, 1960); Hamilton Anxiety Rating Scale (HAMA) for anxiety (Hamilton, 1959 for constipation (Marquis et al., 2005).

PDQ-39
The PDQ-39 SI scores were higher in female patients than in male patients. Men reported lower QoL in mobility, emotional, and pain Augustine et al., 2015 The

Statistical analysis
All data except for the marital status are expressed as mean ± SD. test. Linear regression models were constructed to evaluate the effect of gender differences on PDQ-39-SI after controlling for HAMA, LEDD, RBDSQ, and HRS. We considered p < .05 to be statistically significant.
These statistical data were analyzed using SPSS version 21 (SPSS Inc., Chicago, IL, USA).

RESULTS
A total of 162 (70 males and 92 females) PWP were included. The demographics for 162 PWP are shown in Table 2. We did not observe differences between male and female patients in age, age at PD diagnosis, education years, body mass index, disease duration, and marital status. Male patients had higher LEDD compared to female patients (p<.05).
The clinical characteristics and symptom scale assessments for 162 PWP are shown in Table 3. We did not observe differences between  Figure 1.
Multiple linear regression models of HRQoL scales are shown in Table 5. Sex, LEDD, RBDSQ, HRS, and HAMA were included as independent variables. Sex still had a strong influence on HRQoL after controlling for HAMA, LEDD, RBDSQ, and HRS.

DISCUSSION
The present study demonstrates that gender differences are associ-  worse assessment of QoL in mobility, emotional well-being, social support, and bodily discomfort in Bulgaria. Kuopio et al. (2000) report that women scored significantly lower on five dimensions (physical functioning, role limitations-physical, social functioning, bodily pain, and mental health) in Finland. Meanwhile, Behari et al. (2005) (Qi et al., 2021) and 50% of global PD patients will be Chinese by 2030 (Dorsey et al., 2007), but few studies focus on the QoL in PWP in the Chinese population. Hu et al. (2018) and Song et al. (2014) (Song et al., 2014). To our knowledge, this is the first study that mainly focuses on the effects of gender differences on QoL in a Chinese PD population and all the patients in the early to middle stage. Consisting with previous studies (Augustine et al., 2015;Balash et al., 2019;Behari et al., 2005;Dahodwala et al., 2016;Hristova et al., 2009;Kuopio et al., 2000;Yoon et al., 2017) Apart from QoL, we also found that male patients had a higher RBDSQ score and lower HAMA and HRS scores compared to female patients. So far, the incidence of RBD is also controversial in different studies. some studies reported a higher prevalence in male PD patients than in female patients (Ozekmekci et al., 2005;Yoritaka et al., 2009), but some studies reported opposite results (Bjornara et al., 2013;Bugalho et al., 2011). We found that male patients had higher RBDSQ scores compared to female patients. At the same time, our study showed that male patients had lower HRS scores compared to female patients, suggesting that men have worse olfactory function than women consistent with the previous study (Picillo et al., 2013).
Meanwhile, we also found that females experienced higher anxiety than male patients consistent with the previous study (Leentjens et al., 2011;Liu et al., 2015).
Why do male patients have better QoL than female patients? Anxiety may be one possible reason. Anxiety frequently afflicts PWP and negatively impacts their QoL, especially female patients (D'Iorio et al., 2017;Dissanayaka et al., 2014;Pontone et al., 2019 concern for poor performance. There is substantial research showing that women do more housework than men in East Asian countries (Hu & Mu, 2021;Midgette, 2020;Oshio et al., 2012). Therefore, although our study did not assess the participation of female patients in housework, we still considered it as a possible reason why the QoL of female patients is lower than that of men.
Our study has several limitations. First, we included only PD patients rated between 1 and 3 on the H&Y stage, which might lead to selection bias. Because the study participants were all Chinese population, the generalizability of these observations across the different countries should be verified. Second, the economic status of patients may have a certain impact on their QoL, our study did not include it.
Finally, we conducted a small sample data study and further studies are required before they can be used for clinical management or planning of patient care.
In conclusion, the present study shows that gender differences are associated with the QoL in PD patients. Female patients have poorer QoL than male patients, especially bodily discomfort, stigma, and emotional well-being. When we manage female PD patients, we should pay more attention to bodily discomfort, stigma, and emotional well-being for improving the QoL and inform the family members and caregivers to actively participate in the daily family activities to reduce the living burden of patients, and reduce the psychological burden of patients through positive psychological counseling and health education.

ACKNOWLEDGMENTS
We are grateful to all the patients and the medical staff of the Neu-

CONFLICT OF INTEREST
The authors declare no conflict of interest.

DATA AVAILABILITY STATEMENT
The data of this study are available from the corresponding author upon request.

PEER REVIEW
The peer review history for this article is available at https://publons. com/publon/10.1002/brb3.2517